Category Archives: Labour and Delivery

Measuring Success in Family Planning: Parity and Unmet Need For Contraception in South Asia

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Population growth over time. Note particularly growth rate since the Industrial revolution.  Image credit to Washington Post

Human population growth over the last 2000 years. Note growth since the Industrial Revolution.1

The human population has skyrocketed since the advent of the industrial revolution, leading to the establishment of family planning programs to help curb the number of births in developing nations, where large families often result in increased child and maternal mortality. The aim of these schemes has historically been simply to reduce the number of births per woman, trusting that the economic, environmental, and healthcare crises would then be mitigated by necessity. The reality of “success” has not been uniform, however. In South Asia programs run by outside Nongovernmental Organizations (NGOs) there is a legacy of forcibly implanted intrauterine devices (IUDs),2 sterilization camps,3 and the sale of IUDs to the Indian Government by the World Health Organization and the Ford Foundation with the full knowledge that the Dalkon Shield IUD was puncturing the endometrial wall and causing rupture and hemorrhage in American women4 in addition to the dangers of its removal thread, which was found to be ‘wicking’ moisture, leading to the spread of Escherichia coli5 and causing pelvic infections, thus creating even more infertility among the women who used it.6 Even more shocking was the fact that the IUDs were intentionally shipped with only one inserter per ten IUDs to make them more “cost effective.”7 As late as the mid-1990s (it may still be continuing), women were given an IUD following the birth of their child, even against their wishes. If the woman later wanted this IUD removed, she would be required to pay to for it out-of-pocket at a private clinic.8 These crises in treatment and accessibility options stem from the mindset that parity reduction is the ultimate measure of success, rather than judging by markers of women’s increased empowerment: a decrease in the number of women reporting an unmet need for modern contraceptive methods, an increase in the number of girls in school, and an increase in the number of births attended and monitored during pregnancy by a skilled birth attendant. Moralizing the choices of women of color in developing nations who have more than two children while saying nothing about the real disparity in resource usage between children in developed and developing nations9 overlooks the greater issues into which family planning needs are wrapped: disparity in resource availability and pervasive misogyny.

In her book on birth in Tamil Nadu, Cecilia Van Hollen translates a number of interviews with doctors, nurses, and multipurpose healthcare workers (MPHW) in which poor women are shamed for being “illiterates” who “do not know what is best” and therefore need to have their decisions made for them.10 When a woman is illiterate she is automatically assumed to be incapable of using more complex forms of contraception (i.e. the pill) and therefore often receives no patient counseling on any methods beyond IUDs and sterilization–if she receives any counseling at all. Women’s fertility becomes a focal point for forcing devices and procedures on women against their will and sometimes even without their knowledge. All women in the Tamil hospitals Van Hollen visited were mandatorily inserted with a “loop” (IUD), even if they protested its insertion.11 These women later had to either remove the device themselves (a dangerous option), accept the contraception, or (if she was able) pay approximately 30-50 rupees to have it removed at a private hospital.12 This total disregard for the wishes and rights of women was treated as ‘business as usual’ by the medical practitioner interviewees, who saw it as simply part of knowing what is best for women who by their illiteracy and poverty are rendered incapable of making their own choices.13

comparison

Dalkon shield IUD as compared to a Copper T IUD. 14

In the 1970s, AH Robins developed the Dalkon Shield IUD for the United States market which was “with the possible exception of Norplant,… arguably the worst contraceptive ever foisted upon American women.” By the time it was recalled, 18 women had died, several hundred were subjected to life-threatening, spontaneous15 septic abortions, and several thousand women were made sterile when it perforated their uteri.16 A class action lawsuit was eventually filed in which 167,000 women made claims and billions of dollars were paid out to victims.17 Because of the nature of mortality reporting, it is impossible to know for certain how many women (or their estates postmortem) did not file claims though they were eligible to do so.18 Just before the Dalkon Shield was finally recalled, Robins with the help of USAID, Planned Parenthood International, Pathfinder, and the Ford Foundation shipped the remaining IUDs- knowing that they were already killing women- to low-resource developing nations, where it was deemed that they would be ‘good enough’ for ‘those women.’19

A protest of the Dalkon Shield20

A protest of the Dalkon Shield20

The uterus is a sterile environment21 and thus anything inserted into it must also be sterile or the uterine cavity will become infected (Pelvic Inflammatory Disease–PID), which can lead to sterility, so the microbial cleanliness of an IUD and its inserter is absolutely critical to maintaining a woman’s reproductive health. The IUDs that were sent to South Asia were not sent as was normal for IUDs intended for American and European women. Rather, for every ten IUDs that were shipped one inserter was included.22 Adding to the trouble was that the IUDs were bulk packaged, that is, not sterile, individual packages as they are here, and had one instruction manual was shipped with every one thousand IUDs. 23 These instructions, when a clinic was fortunate enough to receive them, were written only in English, Spanish, and French- none of which are native or official languages in South Asia.24 This alone would have created a massive backlash had it happened in the United States, but goes it relatively unmentioned in reporting on the Dalkon Shield. That an incredibly dangerous device was foisted upon unsuspecting women in a developing nation isn’t mentioned in most reporting on the Dalkon Shield and does not even feature on the IUD’s Wikipedia page.25 This Western-centric myopia has left the literally unknown legions of women and their families locked out of the lawsuits created to gain justice and compensation for victims of the Dalkon Shield. While it is not known exactly how many women were injured or killed by the Dalkon Shield, Pathfinder’s records show that 700,000 Dalkon Shield IUDs were shipped to developing nations.26 By 1986, 192,000 claims had been filed (predominantly in the United States) amounting to $2.3 billion, but there is not a single recorded claim from India.27

Sterilization instruments used in Bihar in 2013.28

Sterilization instruments used in Bihar in 2013.28

Tragically, this pressure for parity reduction continues despite the Indian government’s attempts to ‘change gears’ and reduce abuses.29 The crisis of 4.6 million forced sterilizations in the single year in India30 is shocking. As a woman in a developed country on the payroll for a reproductive rights non-profit who is also beginning to work in family planning in the developing nation context, the figures are particularly alarming. In 2012 the Guardian newspaper revealed that “tens of millions of pounds” of aid money from the United Kingdom had helped to fund such programs, which bribed impoverished women to undergo sterilization, left them “bleeding and in agony,” and resulted in miscarriages and dead babies.31 The tubal ligations32 were performed in rooms with multiple beds to have multiple concurrent surgeries, on bloody sheets, and with rusty scalpels.33 These are all, obviously, incredibly dangerous to the women undergoing the surgeries, which have seen women left on on the ground, outdoors, exposed for “recovery.”34 It’s not particularly difficult to imagine the outrage and lawsuits that would ensue if these atrocities-because that’s what they are-were committed in a Western nation. In the United States much is made of our ‘malpractice litigation-happy’ culture, but it does protect us from abuses like these. The lives of women and our reproductive rights are constantly challenged in the United States,35 but we are at the very least protected from these kinds of horrors.

Women left to recover exposed outdoors post tubal ligation. 36

Women left to recover exposed outdoors post tubal ligation. 36

These completely preventable tragedies are obviously not the intent of the donors and taxpayers who fund the family planning programs behind them, nor are they the result of malicious healthcare workers who want to slaughter their patients, but they are the reality of what occurs when reduction in parity is the primary or only measure of success. When the end goal of a program is simply to reduce the number of children each woman produces, it neglects the reasons why it might be desirable for her to have fewer children: poverty, malnutrition, lack of educational opportunities, healthcare availability, and child marriage, to begin a very long list. It is important to remember that globally only 47% of births are attended by a skilled practitioner,37 1/3 of all girls are married before 18,38 and that 60% of the 61 million children deprived of education are girls.39 These figures are both shocking and unacceptable. It is true that reduction in parity and greater spacing between children does increase the mother and child’s chances of survival, but it is paternalistic (and neo-colonialist for western foundations) to tell women in developing nations how many children they are allowed to have or forcibly create a reduction in fertility.

A keychain featuring the family planning slogan “we two, our two” in Hindi. 40

A keychain featuring the family planning slogan “we two, our two” in Hindi. 40

I am not insinuating that these abuses are the intent of any modern family planning program in the developing world, but the pressure to produce results is particularly dangerous when the result is simply a reduction in the number of children a woman births. The current model has MPHCW receiving bonuses for “acceptors” and seeing demotion when their “goals” are unmet.41 With those kinds of structures in place it is little wonder why coercion in family planning is so common. The measure of the success of a family planning program is the reduction of a woman’s indicated unmet need for contraception and the path to that success is the elimination of child marriage, universal access to high-quality education for all children, and the ensurance that all children are adequately nourished. There are, of course, other important issues to ensure gender equity and that women are given the opportunity to rise out of poverty (see Millennium Development Goals), but those are good first indicators.

Branded packaging for the PATH SILCS one size diaphragm. 42

Branded packaging for the PATH SILCS one size diaphragm. 42

Making multiple methods of woman-controlled, side-effect free contraception available to women has been shown to increase the long-term use of contraception.43 When women control their contraceptive choice and understand the method, they are more likely to use it long-term and to use it correctly. Fortunately, a woman-controlled, low-cost, long-term, side-effect free method has been available since the 1930s, though it has fallen out of popularity since the advent of the birth control pill: the diaphragm. The diaphragm’s primary difficulty was that it required fitting by a trained professional, but a new diaphragm developed by Seattle-based NGO PATH is single-sized, eliminating the need for a fitting. Even the old belief that the diaphragm is best suited to women who do not have sex often has been shown as not accurate. Even women who have more frequent sexual encounters (4 or more times a week) rate diaphragms as highly acceptable.44 The more flexible and varied a woman’s choice, the more clear and concise the information given to her, the more empowered the woman will be. Family planning is powerful and necessary because it can make an incredible difference in women’s lives, but it can’t do that through coercion, abuse, and the withholding of information.

1 Image credit: Brad Plumer, Washington Post, 1 November, 2011 http://www.washingtonpost.com/blogs/wonkblog/ post/chart-of-the-day-our-exploding-population/2011/11/01/gIQAVOIScM_blog.html

2 Cecilia Van Hollen, “Moving Markers” from Birth on the Threshold: Childbirth and Modernity in South India, (University of California Press, Beekley), 2003

3 Andrew MacAskill, “India’s poorest women coerced into sterilization,” Bloomberg, 11 June, 2013l http://www.bloomberg.com/news/2013-06-11/india-s-poorest-women-coerced-into-sterilization.html

4 James A Miller, “The case of the Dalkon Shield,” http://pop.org/content/money-for-mischief-usaid-and-pathfinder-1694 (accessed 14 October, 2013)

5 HJ Tatum, FH Schmidt, D Phillips , M McCarty, WM O’Leary, “The Dalkon Shield controversy. Structural and bacteriological studies of IUD tails.” JAMA. 7 (1975); 231, 711-7 http://www.ncbi.nlm.nih.gov/pubmed/1172860

6 James A Miller

7 James A Miller

8 Cecilia Van Hollen, 158

9 For some humbling statistics on resource use and population, Washington State University has created a page based on information from the World Bank. http://public.wsu.edu/~mreed/380American%20Consumption.htm

10 Cecilia Van Hollen, 166

11 Cecilia Van Hollen, 149-51, 156-57

12 Cecilia Van Hollen, 150

13 Cecilia Van Hollen, 155

14 Image credit to University of Virginia School of Law, http://lib.law.virginia.edu/specialcollections/records/mss/ 00-4

15 Jennifer Couzlin-Frankel, “Contraceptive comeback: The maligned IUD gets a second chance,” Wired, 15 July 2011, http://www.wired.com/magazine/2011/07/ff_iud/

16 Jennifer Abbasi, “4,000 years of birth control and counting,” Everyday Health,1 June, 2013 http:// http://www.everydayhealth.com/sexual-health-pictures/4000-years-of-birth-control-and-counting.aspx#/slide-14;
Jennifer Couzlin-Frankel;
Morton Mintz, At any Cost: Corporate Greed, Women, and the Dalkon Shield (New York: Pantheon, 1985), pp. 3–4.

17 James A Miller

18 James A Miller

19 James A Miller

20 Image credit to: Jennifer Abbasi

21 BR Moller, FV Kristiansen, P Thorsen, L Frost, SC Morgensen “Sterility of the uterine cavity,” Acta-Obstet Gynecol Scandanavia (1995), 74(3), 216-9

22 James A Miller

23 James A Miller

24 Technically India has no official language and English is widely understood, but in rural areas it is not the common language of the people and is less well known. Particularly in the case of medical issues, instructions should always be in a language well understood by the practitioner and patient to avoid potentially life-threatening mistakes.

25 http://en.wikipedia.org/wiki/Dalkon_Shield

26 James A Miller

Morton Mintz

27 Gabriella Wass, Corporate Activity and Human Rights in India, (Human Rights Law Network, New Delhi, 2011)p. 56

28 Image credit to Andrew MacAskill/Bloomberg. “Surgical instruments used in the sterilization procedure are seen in a tray in a clinic in Sonhoula, Bihar state, India.”

29 Cecilia Van Hollen, 163-165

30 “India’s forced sterilisation nightmare,” Aleteia, 11 July 2013, http://www.aleteia.org/en/world/documents/indian-voluntary-population-control-2304002

31 Gethin Chamberlain, “UK aid helps to fund forced sterilisation of India’s poor,” The Observer via The Guardian, Saturday 14 April 2012, http://www.theguardian.com/world/2012/apr/15/uk-aid-forced-sterilisation-india

32 The surgical procedure to permanently sterilize a female-bodied person. The woman’s abdominal cavity is opened and her fallopian tubes are cut, tied, and cauterized (burned).

33 Andrew MacAskill

34 Celeste McGovern, “Who’s behind India’s barbaric mass sterilization camps?,” Life Site News, 11 March, 2013, http://www.lifesitenews.com/news/whos-behind-indias-barbaric-mega-sterilization-camps/

35 Adalia Woodbury, “Republicans have launched 694 attacks on women’s reproductive rights in 3 months,” Politico, 14 April, 2013 http://www.politicususa.com/2013/04/13/republicans-propose-694-attacks-womens- reproductive-rights-3-months-2013.html
Bodine, Larry, The nationwide attacks on reproductive rights (12 June, 2013), http://www.huffingtonpost.com/larry- bodine/it-started-in-arkansas-wh_b_3418944.html

36 Image credit to Carol Kuruvilla,,” Horror in a mass sterilization camp: unconscious indian women were dumped in a field after undergoing painful sterilization operation,” Ny Daily News, 7 February, 2013, http:// http://www.nydailynews.com/news/national/indian-women-dumped-field-sterilization-operation-article-1.1258314

37 WHO, http://www.who.int/gho/maternal_health/skilled_care/skilled_birth_attendance_text/en/ (accessed 14 October 2013)

38 International Center for Research on Women, http://www.icrw.org/child-marriage-facts-and-figures (accessed 14 October, 2013)

39 Campaign for Education USA, http://www.campaignforeducationusa.org/educating-girls-women-in-developing- countries (accessed 14 October, 2013)

40 “We two, our two” family planning awareness program, India. Image credit to e-junkie.info http://www.e- junkie.info/2011/11/giveaway-chumbaks-fun-vibrant-keychains.html

41 Cecilia Van Hollen, 158

42 Image credit to PATH A Catalyst for Global Health http://www.path.org/projects/silcs.php

43 Nuriye Ortayli, Aysen Bulut, Hacer Nalbant, and Jane Cottingham, “Is the Diaphragm a Viable Option for Women in Turkey?” International Family Planning Perspectives, Vol. 26, No. 1 (2000), p. 36 http://www.jstor.org/stable/ 2648288 .

44 Julie E. Maher, S. Marie Harvey, Sheryl Thorburn Bird, Victor J. Stevens and Linda J. Beckman, “Acceptability of the Vaginal Diaphragm among Current Users,” Perspectives on Sexual and Reproductive Health, Vol. 36, No. 2 (2004), p. 64 Nuriye Ortayl, et. al., p. 38

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February C-Section Studies

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February has been a busy month in our house (Baby Rónán is turning 6 months) and seems to have been just as busy for researchers publishing findings on C-Sections. It’s no secret that birthing vaginally is superior for both mother and baby’s health, but it is shocking how much information is kept from women about exactly how risky a cesarean is and how likely they are to have one. A cesarean section is major abdominal surgery, but pregnant mothers are often frankly bamboozled into thinking that it’s “no big deal” and that the medical interventions being imposed on them make it significantly more likely that they will have one.

Continuous Fetal Monitoring Linked to Higher Cesarean Rates

Originally developed for high-risk pregnancies, the now common practice of continuous fetal heart monitoring (CTC- cardiotocography) has been linked to higher rates of cesareans, which are being used to resolve what are just safe fluctuations in the baby’s heart rate. According to Medical Express and Dr. Lee Learman, M.D. of the Indiana University School of Medicine

“We now know that this form of monitoring has not improved clinical outcomes,” he explained. “Instead, because of its inherent limitations, this form of monitoring leads to many ‘false alarms’ that are resolved by performing cesarean delivery.”

The cumbersome wires of the monitoring system (even with telemetry) make it very difficult for the labouring mother to move freely and bathe, which speeds labour along and can make it significantly less painful for the mother. If CTC is indeed increasing the likelihood of an unnecessary C-Section for the mother and simply causes her inconveniences which make the labour process more difficult, it begs the question of why so many women continue to be told that it’s “necessary” at all. The issue of continuous (rather than intermittent) fetal monitoring is a perfect time for a mother to exercise her right to say “no” to any procedure. All patients have the right to deny all or part of the recommended care at any point.

Respiratory Illness Rates Higher In C-Section Babies

“Research by the March of Dimes and the Centers for Disease Control and Prevention in 2008 found that c-section deliveries accounted for nearly all of the increase in the U.S. singleton preterm birth rate between 1996 and 2004.”

That statement alone is worrying enough, but the article also raises the issue that babies born “small for gestational age babies delivered early by c-section had higher rates of respiratory distress syndrome than similar preterm babies who were born vaginally.” It used to be that doctors could genuinely say that cesareans carried no additional risk to mother and baby, but now we know it isn’t true. Aside from the problems it can cause with the establishment of breastfeeding, we now know that leads to a greater likelihood that baby will have respiratory issues. Every mother wants what is best for her baby and that clearly isn’t a c-section in most cases. On a recent visit to a hospital with a client, the nurse doing the tour casually answered my standard “what is your c-section rate” question with a cool 33% For reference, the World Health Organization says that the C-Section rate should be between 10-15%– less than half of what that hospital was doing. I was floored by that number and even more shocked that she didn’t seem at all ashamed and offered no reason why it should be so high. I look forward to the day when hospitals have to justify these numbers to patients and doctors don’t perform major abdominal surgery on mothers to suit anyone’s convenience. When a baby is born vaginally he receives a coating of microflora from the mother’s vagina, her body releases a rush of oxytocin to bond with her and causes her milk to drop, and the mother and child have the shortest recovery time. Preventing a c-section should be among the top priorities of birthing institutions and OBs.

C-Section Linked To Breathing Problems In Pre-Term Infants

More of the same, mostly, but including this interesting tidbit:

Preterm birth, which is delivery before 37 weeks of pregnancy, is a serious health problem that costs the United States more than $26 billion annually, according to a 2006 Institute of Medicine report.

It also elaborates that the above study took into account the usual suspects for discrepancy in maternal stats: “maternal age, ethnicity, education, primary insurance payer, pre-pregnancy weight, gestational age at delivery, diabetes and hypertension.”

Pregnant Women With Prior Cesarean Choose Delivery Method Preferred By Doctor

VBAC (vaginal birth after cesarean) is a safe, viable option for many women. Unfortunately, most of them are scared off it by doctors who fear that the fraction of 1% chance of uterine rupture will happen to their patient on their watch. However, they seem to have no problems using Cytotec (misoprostol) to induce labour, even though it is definitely proven to be very dangerous to induce labour-especially in women with a prior cesarean section.

“Even though most women can achieve a vaginal delivery with trial of labor, less than 10 percent of them attempt to do so,” said Sarah Bernstein, MD, with St. Luke’s- Roosevelt Hospital Center, Obstetrics and Gynecology, in New York, and one of the study’s authors. “In fact, when patients perceived that their doctor preferred a repeat cesarean, very few chose to undergo trial of labor, whereas the majority chose trial of labor if that was their doctor’s preference.”

It is absolutely shameful that doctors should knowingly (or unknowingly- ignorance of best practice is not an excuse for poor practice) put mothers and babies at risk. Stand up for your rights and welfare, Mothers!

**Can you tell I love Medical Express? It’s a great one-stop source for research releases. LOVE IT.

UW Proposes Cutting Nurse-Midwife Program

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The Seattle Times reported this week that the University of Washington School of Nursing is proposing cutting funding to its midwifery program. While it is true that all belts need to be tightened at the University (except the athletic department’s), the midwifery program is an asset to our community here in Seattle*. Natural birthing is an important first gift that a mother can give to her child and herself, but sadly a natural hospital birth is difficult to attain. Mothers are offered interventions without being fully informed by their doctors of the complications that can arise from them and the United States is packing a 31% cesarean rate. Having a nurse-midwife can help mitigate some of those risks since they are are licensed to attend births in hospitals- a happy medium  for a family wanting a natural birth and the safety net of being in a hospital or for a higher risk pregnancy that isn’t a candidate for a birth center/home birth. Bastyr University in Wallingford also has a midwifery program, but theirs are licensed midwives, a completely separate category.  My midwife was trained at Bastyr, but did not have hospital birthing privileges, so when I was transferred to the UW Medical Center, I was unable to have my practitioner attend my son’s birth.

 

I don’t know what should be cut instead or how exactly the money should be allocated to keep the program afloat in these difficult times, but I do know that women need midwives, regardless of where they’re birthing and that taking away the midwives ultimately will hurt our society more than another cut might. Without naming department names, I know of a couple that simply don’t serve our culture on anything close to the same level. We should be finding new ways to cut healthcare costs, not cutting the programs that are saving lives and dollars.